Rural Barriers: Healthy Lifestyles Program, Using Diabetes as a Model

1. Rural Barriers: Healthy Lifestyles Program, Using Diabetes as a Model Diane Spokus Doctoral Candidate The Pennsylvania State University Workforce Education/Training & Development

2. Background • PEPPI • ACTIVE • AHEC • Continuing Professional Development Programs/Health Education • Adult Aging & Development/Biobehavioral Health • Hartford Foundation (www.hhdev.psu.edu) • Retaining, Managing & Retraining Older Workers

3. Americans’ use of information technologies has grown in many locations including the workplace, the schools, the home but not as rapidly in lower-income housing and retirement residences or church organizations where older adults congregate.

4. Healthy Lifestyles Program Sponsored By • The Division of Endocrinology of • The Department of Internal Medicine and the • Department of Family and Community Medicine • Pennsylvania State University College of Medicine and • Pennsylvania Area Health Education Centers (AHEC) • Sponsored by: • Diabetes Control Program • Pennsylvania Department of Health

5. AHEC MISSION The mission of the Pennsylvania AHEC Program is to help communities meet their primary health care needs

6. by creating a statewide infrastructure bridging community and academic resources to:

7. Recruit and retain primary care providers in underserved communities.

8. NEEDS LOCAL SOLUTIONS • Each underserved community & individual has a different set of needs that must be identified andaddressed.

9. AHEC Housed in 45 States

10. Southcentral PA AHEC Region

11. Goal Today • To discuss the opportunities for improvement in the delivery of community-based health education programs for older adults living in rural areas.

12. Objectives Today • To discuss the Healthy Lifestyles Program • To examine rural barriers to success in implementing community-based programs for older adults • To identify the physiological differences that occur in the aging process that require adaptive technology

13. Objectives of the Healthy Lifestyle Program • Increase the awareness of the population in the area that everyone is at risk for a chronic disease • Develop and implement a community training program to empower the target audience with tools to improve their lifestyles • Evaluate the training program through a pre- and post-trainee assessment

14. Target Audience • Older adults in low-income hi-rises, retirement communities, long-term care, assisted care facilities, church groups, and Pennsylvania Department of Aging Area Agencies on Aging. • Increased need in communities to obtain free community-based health education programs.

15. Risk Factors • Overweight • Older population is at greater risk for obesity-related health conditions such as hypertension, diabetes mellitus and hyperlipidemia. • Two major factors behind obesity include • Inactivity • Poor dietary habits • 45 years of age or older • Inactive lifestyle • Woman having had a child weighing 9 pounds or more • Family history of diabetes

16. Physical Activity • Regular physical activity • for older adults can have an enormous effect on their independence level and quality of life. • Older adults at a greater risk for developing chronic diseases • such as diabetes, heart disease, or hypertension • Motivation • is the key to maintaining an active lifestyle

17. Number of People with Diabetes • United States 13 million • Pennsylvania 660,000 People with diabetes that do not know it: • United States 5.2 Million

19. Facts • In 1992 – 30 million persons over 65 • In 2000 – 34 million persons over 65 • About 5%, or over 1 million will be residents of an institution • Most older men are married; most older women are widowed • 86% suffer from one or more chronic health conditions • > age 65, 23% limited in their activities of daily living Source: National Center for Health Statistics. (1992). Facts about older Americans. Washington, DC: Author

20. Facts • People > age 65 • hospitalized twice as often as people under 65 • People > age 65 • hospital visits average 50% longer • People > age 65 • use twice as many prescriptions. • Fastest U. S. growing population • > age 85 Source: National Center for Health Statistics. (1992). Facts about older Americans. Washington, DC: Author

23. Healthy Lifestyles Program, Using Diabetes as a Model Train-the-Trainer Program • Volunteers from the community who attend two-hour interactive training programs on how to facilitate the Healthy Lifestyles Program • Recruited from organizations, parish ministries and health professions students wishing to do community work.

24. Area Agencies on Aging • Implement various programs for older Pennsylvanians. • 52 such Pennsylvania offices • Serving all 67 counties • Staffed with caseworkers skilled in such areas as geriatrics, social work and community resources • Assist older adults with questions • regarding nursing facilities • community services in nursing facility placement, • and a wide range of other community services tailored to your specific needs.

25. Pennsylvania’s 67 Counties

26. Program Timeline • Summary reports to Department of Health every 12 months • Under Pennsylvania Department of Health contract to implement 16 programs per year. • First Month: • Coordinator identified sites for courses • Second Month: • The first trainee program for Facilitators held at College of Medicine.

27. MARKETING • The Third Month: • Advertisement began for course participants and continued throughout the remaining months. • Notices in church bulletins, newspapers, Area Agencies on Aging, Retiree residences, low-income housing. • First courses implemented • Provided exercise and nutrition books as incentives

28. Intervention • Provide a one-time only follow-up session between one to two months to provide support to the individuals. • Also, link individuals to community resources

29. Results From June, 2002 to July, 2004 • Number of Train-the-Trainer Programs 6 • June 4, 2002 – 4 • June 11, 2002 – 10 • July 2, 2002 – 8 • July 9, 2002 – 2 • September 26, 2002 - 14 • July 23, 2003 - 5 • Number of Trainees 43 • who have participated in trainer program

30. Participants • From June, 2002 to July 1, 2004 • 66 Healthy Lifestyle Programs conducted • 887 individuals participated • particularly lower socio-economic groups, including minorities participated

31. Attrition Note: Due to facilitator attrition, we could only depend on 5 new facilitators and 2 seasoned facilitators, including myself for community-based programs. • Reasons: Volunteer facilitators had good intentions; however, when programs are held during the day, there are work conflicts • In-Kind Contributions – approximately $17,000

32. EVALUATION • Pre-post tests and follow-up questionnaires/surveys were used to determine how many people were able to change at least one unhealthy behavior and how much physical activity changed as a result of the educational program

33. Pre/Post Test Questions Likert Scale (1 Disagree to 5 Agree) • This program gave me information that I did not know before. • I learned how to live a healthy lifestyle. • I am more aware of the risk factors of diabetes. • I can name one healthy eating guideline that I can follow. • I can name one way I can increase my activity level. • I can understand the importance of using the wallet card. • I would recommend this program to my friends, family and people I meet. • I was able to understand the material presented.

34. Facilitator’s Evaluation Questions • Is the program written at an appropriate reading level for the general public? • Is the content appropriate for the general public? • Does the content provided achieve the stated objectives? • What suggestion do you have to change the content of the program? • What suggestions do you have in presenting the material? • Is the Trainer’s Manual complete enough to give the trainer enough information to address the audiences concerns?

35. Facilitator Evaluations (cont’d.) • If the audience has questions, that the trainer cannot answer, should they: • Contact the people that trained them? • Refer them to an educator in the area? • Refer them to their provider? • Leave it up to the discretion of the trainer? • Other (specify)_____________________ • Do you have any other suggestions or comments about the program?

36. Barriers • Lack of funding for successful delivery of rural health education program • Educational level (reading level, verbal abililty) • Race and ethnicity (language barriers); need for more Spanish-speaking facilitators • Income (inability to afford hearing aids, glasses) • Health (age-related declines)

37. Observations in the Field • Cognitive difficulties in completing some simple pre/post test questions • Need for material for various educational levels which may be accomplished through adaptive technology • Increased lay person training in use of medical devices such as infusion pumps, blood pressure monitors, etc. • Medications not taken properly (instructions too quick to grasp) • Hearing losses provided a challenged in giving directions; battery-operated hearing aid transistors would have helped participants more actively participate • Visual problems – although we had packets in large print, there was a need for technology in the field to present the material in different modalities, such as PowerPoint, microphone, virtual presentations, etc.

38. Recommendations • Stimulate an increase in funding to provide computer and internet capabilities to community-based organizations that service older adults. • Related to the above, increase the use of technology particularly to Area Agencies on Aging, retirement communities and low-income hi-rises that service older adults. • Facilitate health care delivery communication in different formats that attracts different educational levels and compensates for age-related changes. This would include keeping an audience motivated through animation, video, and experiential tasks. Older adults may need to learn something new through several modalities: seeing it, hearing it and doing it. • Build partnerships to avoid duplication of services • Provide technology training to facilitators as well as to participants

39. Age-Related Changes • Vision • Lens yellows and thickens • Muscles controlling pupil size weaken • Result – need for additional light • >65 years old →2x as much light as younger Lens person • Lens grows unevenly → glare • Color perception → pastels look alike; darker colors indistinguishable • Cataracts → cataract glasses thick to compensate for the lack of a natural lens • Macular Degeneration → central vision loss Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished Manuscript. Riverwoods, IL: Rehabilitation Associates.

40. Ways to Help • Use non-verbal feedback through touch to compensate for visual deficits—can’t see those warm smiles • Adjust shade, tablecloths, curtains to avoid glare • Sunglasses, hats • Provide adequate lighting • Color coding doesn’t help in taking meds; contrast colors • Gradual lighting helps; e.g., night lights • Reassure them of their appearance • Finger foods Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished Manuscript. Riverwoods, IL: Rehabilitation Associates.

41. Normal Aging Hearing • Presbycusis →  for men • Hearing worse at high frequency; sounds distorted • Loss  for consonants than vowels. S,Z,T,F, and G sounds difficult to discriminate • ↓ Well-being, paranoid reactions common • Important for communication & safety Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished Manuscript. Riverwoods, IL: Rehabilitation Associates.

42. Ways to Help • Provide amplifiers to older adults when doing community-based program • Overall program evaluations are not always credible when you have individuals filling out pre/post test forms who can’t hear directions, etc.

43. Normal Aging • Neurological Changes • Instructions and information on disease may be too complex • 7% ↓in brain size; nerve cells lost • Older adults earn ↓ scores compared to young • Age differences represent decline in ability tested or  cautiousness of individual ↓speed of processing • Exaggerates declines in memory and learning • Less willing to “guess” •  long term memory when instructed to organize material in brain for processing & storage • Recall, recognition & mneumonics— “tricks of the trade” Richman, N., & Glantz, C. (1992a). Sensory deficits and ways to help. Unpublished Manuscript. Riverwoods, IL: Rehabilitation Associates.

44. Healthy Lifestyles Participant Manual What is Diabetes? • It is a serious, chronic disease in which you have a high blood sugar level due to a lack of insulin • Insulin is needed to take the glucose (sugar out of the bloodstream and move it into the body’s cells to use for energy

45. What is Diabetes? • It is a serious, chronic disease in which you have a highblood sugar level due to a lack of insulin • Insulin is needed to take the glucose(sugar) out of the bloodstream and move it into the body’s cells to use for energy

46. Type 1 Genetic Self-allergy Environmental (virus) Type 2 Family members with Type 2 diabetes Being overweight Physically inactive Dietary intake Advancing Age Ethnicity (Race) Risk Factors

47. Types of Diabetes • Type 1Type 2 • No InsulinNot enough insulin produced producedBody unable to use insulin produced

48. Type 1 Frequent urination Very thirsty/hunger Feeling very tired Blurred vision Unexplained weight loss Type 2 Frequent urination Very hungry/thirsty Feeling very tired Blurred vision Slow healing cuts Frequent infections No symptoms at all Signs and Symptoms of Diabetes

49. What Happens When You Eat • Cells in your body need sugars and starches for energy to do their job • Food you eat is turned into sugar and starches by the stomach • Sugars and starches are carried in the bloodstream to the cells • The pancreas makes more insulin – the key- that opens the doors of the cells so the sugar goes into the cell

50. What Happens When You Eat = Sugar = Insulin